Abstract

Background & Aims Recurrent and refractory Clostridium difficile infections (CDI) are effectively treated with fecal microbiota transplant (FMT). Uncertainty exists regarding the effectiveness of FMT for CDI with underlying inflammatory bowel disease (IBD), its effects on disease activity and its effectiveness transferring the donor microbiome to patients with and without IBD. This study aims to determine FMTs effectiveness in subjects with and without IBD, its impact on IBD activity, the level of microbiome engraftment, and predictors of CDI recurrence.

Methods Subjects with and without IBD who underwent FMT for recurrent or refractory CDI between 2013 and 2016 at The Mount Sinai Hospital were followed for up to 6 months. The primary outcome was CDI recurrence 6 months after FMT. Secondary outcomes were (1) CDI recurrence 2 months after FMT; (2) Frequency of IBD flare after FMT; (3) Microbiome engraftment after FMT; (4) Predictors of CDI recurrence.

Results Overall, 134 patients, 46 with IBD, were treated with FMT. There was no difference in recurrence in patients with and without IBD at 2 months (22.5% vs 17.9%; p=0.63) and 6 months (38.7% vs 36.5%; p>0.99). Proton pump inhibitor use, severe CDI, and comorbid conditions were predictors of recurrence. The pre-FMT microbiome was not predictive of CDI recurrence. Subjects with active disease requiring medication escalation had reduced engraftment. There was no difference in engraftment based on IBD endoscopic severity at FMT.

Conclusions IBD did not affect CDI recurrence rates 6 months after FMT. Pre-FMT microbiome was not predictive of recurrence, and microbial engraftment was dependent on IBD treatment escalation but not on underlying disease severity.

Footnotes

↵* Robert P Hirten, Ari Grinspan, Shih-Chen Fu should be considered joint first authors

Grant Support: This study was funded in part by the SUCCESS (Sinai Ulcerative Colitis Clinical, Experimental and System Studies) grant from the Bacchetta Foundation (SCF, IP, JHC, JFC, JJF, JCC), the Crohn’s and Colitis Foundation of America grant #362048 (JJF, JCC), and the George Waechter Memorial Foundation grant (AG).

Abbreviations

Anti-TNF

anti-tumor necrosis factor

AZA

azathioprine

BMI

body mass index

CD

crohn’s disease

CDI

clostridium difficile infection

CDIR

clostridium difficile infection relapse

CRP

c-reactive protein

ESR

erythrocyte sedimentation rate

FMT

fecal microbiota transplant

GERD

gastroesophageal reflux disease

HBI

Harvey Bradshaw Index

IBD

inflammatory bowel disease

Non-IBD

non-inflammatory bowel disease group

IBDe

inflammatory bowel disease medication escalation

IBDs

inflammatory bowel disease no medication escalation

J tube

jejunal tube

LSM

least-squares means

MP

mercaptopurine

MTX

methotrexate

OTUs

operational Taxonomic Units

PCoA

principal coordinate analysis

PEG

percutaneous endoscopic gastrostomy

PPI

proton pump inhibitor

PUD

peptic ulcer disease

SD

standard deviation

SES-CD

simple endoscopic score for Crohn’s disease

UC

ulcerative colitis

WBC

white blood cell count

Writing Assistance: No writing assistance was provided to the authors.

Disclosures: RPH served as a consultant, advisory board member or speaker for Janssen and Takeda.